I authorize Dr. B. Alex Vakili and or his designee, to perform IPL (Intense Pulsed Light) skin treatments on me, including, but nnot limited to, the treatment of pigmented lesions (for example: sun spots, age spots and other skin discolorations), vascular nlesions (for example: red spots, leg veins and small spiders veins, but not varicose veins), wrinkles (rhytides), furrows, fine nlines, textural irregularities, non-ablative skin resurfacing, soft tissue coagulation, ablative skin resurfacing, and reducing or neliminating hair. I understand the procedure is purely elective, that the results may vary with each individual, and multiple ntreatments may be necessary.
  • Acknowledgement of Cancellation/Refund Policy

    I understand that if I need or want to change or cancel an appointment with Lucencia Medical Spa, I must do so during Lucencia’s regular business hours. I further understand that I must do so no less than two business days before the appointment.
    Furthermore, I understand that I must make this change with one of Lucencia Medical Spa’s staff members in person or by phone. Leaving a message on the answering machine will not be sufficient to cancel or change my appointment. I further understand that if I fail to abide by this cancelation policy I will be responsible for a late cancellation fee of $50.00, which is to be paid in full immediately. Failure to pay this late cancelation fee will result in additional expenses for me including, but not limited to, interest, collection costs and attorney fees.
    *We do not give refunds on our services or products.
    *We do not take back products.
    *All packages must be paid upfront to receive discount offers.
  • Date Format: MM slash DD slash YYYY
  • Optional Information

    The information below is optional and not required for form submission. Entering your e-mail address will sign you up for occasional promotion emails and newsletters from Orlando Heart Specialists, Lucencia Medical Spa, and Center for Vein and Vascular. We will never sell your information.